Pine Lawn Manor
Facility I.D. Number: 0045708
Date of Survey:07/30/2003
Incident Report Investigation of 07/04/2003 AND 07/09/2003
The facilitys governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served.
The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the Administrator. The policies shall be available to the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually.
Residents shall only be admitted who have had a comprehensive evaluation covering physical, emotional, social and cognitive factors, conducted by an appropriately constitutional interdisciplinary team.
The facility shall develop and implement a policy concerning local law enforcement notification, including:
Ensuring the safety of residents in situations requiring local law enforcement notification;
Seeking advice concerning preservation of a potential crime scene.
Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the residents. At a minimum, there shall be at least one staff member awake dressed and on duty at all times.
An appropriate, effective and individualized program that manages residents behaviors shall be developed and implemented for residents with aggressive or self-abusive behavior. Adequate, properly trained and supervised staff shall be available to administer these programs.
There shall be available sufficient, appropriately qualified training and habilitation personnel, and necessary supporting staff, to carry out the training and habilitation program. Supervision of delivery of training and habilitation services shall be the responsibility of a person who is a Qualified Mental Retardation Professional.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 of the Act)
A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. (Section 3-610 of the Act)
RESIDENT AS PERPETRATOR OF ABUSE: WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT ANOTHER RESIDENT OF THE LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT RESIDENTS CONDITION SHALL BE IMMEDIATELY EVALUATED TO DETERMINE THE MOST SUITABLE THERAPY AND PLACEMENT FOR THE RESIDENT, CONSIDERING THE SAFETY OF THAT RESIDENT AS WELL AS THE SAFETY OF OTHER RESIDENTS AND EMPLOYEES OF THE FACILITY. (Section 3-612 of the Act)
These Regulations are not met as evidenced by:
1. Based on interview and record verification, the facility:
a) failed to implement R1's behavior management program to keep her from eloping from the facility.
b) failed to assure adequate staffing to meet the safety needs of R1.
c) failed to assure that staff were adequately trained to implement R1's behavior management program and to meet her safety needs.
d) failed to conduct a thorough investigation of the elopement.
e) failed to develop and implement appropriate corrective action after the incident, also affecting R2, R3, R7, R13, R14, and R15 who have required individual staff supervision (1:1) due to elopement, wandering, anxiety, or aggressive behaviors.
2. Based on interview and record verification, the facility:
a) failed to provide nursing follow-up for R2 after the incident with R3.
b) failed to conduct a thorough investigation of the incident of 07/09/03 for R2 and R3.
c) failed to develop appropriate corrective action.
d) failed to involve the Interdisciplinary Team with admission decisions concerning R2 and R3.
e) failed to notify Administrator and failed to investigate additional incidents of possible sexual assaults.
f) failed to obtain accurate assessments and background information for prospective residents before being admitted to the facility.
g) failed to assure adequate staffing to protect other residents from clients with aggressive behaviors which affected R4, R5, R6, R7, R8, R9, R10, and R16 with the potential to impact all residents in the facility. (R1- R46).
h) neglected R2, R3 and other residents by failing to implement measures to protect them from inappropriate sexual, and other aggressive behaviors.
1. R1 is a 32-year-old female who functions at the moderate level of mental retardation with additional diagnoses of Paranoid Schizophrenia, Anxiety and Depression.
Per facility incident report, dated 07/04/03, R1 left the facility without staff awareness of her absence "at approximately 9:45 p.m. to 10:15 p.m." According to the incident report, R1 had "walked to the highway where she was found and brought back to the facility by a county policeman after he contacted us by phone".
Review of the County Police Accident Report confirmed that a local police officer responded to a "report of a female walking" along the highway at 10:30 p.m. on 07/04/03. The police report indicated that R1 was brought back to the facility and R1 exited the police car at 10:48 p.m.
Telephone interview with Z1 (police officer), on 07/21/03 at 2:30 p.m. confirmed that R1 had been spotted walking along the highway on the night of 07/04/03 by community residents. Z1 explained that this highway is approximately 1.5 miles from the facility and is a highly traveled state highway. Z1 stated that the individuals who found R1 were concerned about R1's safety so the wife stayed with R1 while the husband went to report this incident to the police. Z1 confirmed that when he was alerted to the incident, he called the facility to ask if they were missing a resident. Z1 stated that the facility did not know if they were missing anyone, that "they would have to check around".
Z1 also confirmed that, initially, R1 was not upset when he picked her up on the highway. Z1 stated that R1 said she only wanted to go get some ice cream and asked the officer if he would take her. When the police car approached the facility, however, R1 then became upset, started crying and refused to exit the police car. Z1 confirmed that facility staff had to talk to R1 for quite a long time before coaxing R1 from the vehicle.
A.) Failure to implement behavior programs:
Per review of R1's behavioral objectives, dated 8/02, R1 is on three behavior programs. According to R1's behavior plan to address elopement, R1 "staff will closely monitor resident's general mood", redirect her by trying to get her to write a letter to her mother and "if agitation continues, follow physical aggression program".
Per review of R1's behavior plan for physical aggression (undated), staff are to "stay in close proximity until R1 is completely calm". Record review also confirmed that R1 is on an additional behavior plan to address "crying, yelling, screaming; suicidal threats". This plan states that R1 "is not to be left unsupervised until she has calmed down" and explains that R1's "depression often turns into aggression".
Per R1's Individual Program Plan (IPP), dated 06/11/03, in order of priority, elopement was listed as the third priority of 10 prioritized objectives, R1 "will exhibit 0 episodes of trying to leave the grounds without permission per month by 6/04".
Interview with E9, QMRP (Qualified Mental Retardation Professional), on 07/21/03 at 4:17 p.m. confirmed that R1 has been on an elopement program for a long time and documentation should be recorded on the documentation sheets regarding R1's attempts to leave the facility.
Review of R1's record verified the following incidents as recorded in nursing notes/assessments:
07/09/03 - "resident upset after evening meal; left building".
06/29/03 - R1 "ran from the dining room crying and yelling and ran into the parking lot".
06/18/03 - attempted elopement of R1 on 06/18/03.
12/17/02 - "resident left the facility through the front doors".
11/02/02 - R1 was "up and about since 2:00 a.m., pacing, increased anxiety, crying, wants to go home going outside walking to road".
Review of data collection sheets in the progress section of R1's chart confirmed that the following additional incidents of attempted elopement were documented:
06/03 - 14 incidents
05/03 - 3 incidents
04/03 - 1 incidents
02/03 - 5 incidents
01/03 - 1 incidents
12/02 - 15 incidents
11/02 - 20 incidents
10/02 - 3 incidents
09/02 - 3 incidents.
Per interview with E5, LPN, on 07/17/03 at 6:10 p.m. E5 confirmed that R1 had been upset for several days prior to her elopement on 07/04/03 because she had not been able to contact her mother. E5 explained that this is a common occurrence and when R1's mother won't answer her phone or is unavailable to talk to R1, she becomes very agitated.
Per interview with E9, QMRP (Qualified Mental Retardation Professional), on 07/21/09, E9 verified that R1 has never been on a monitoring program, such as 15 minute checks. E9 confirmed that R1 had not been put on any type of monitoring system/schedule after her elopement on 07/04/03. E9 stated that staff should have followed R1's behavior objectives which includes redirection and close supervision when necessary.
B.) Failure to assure adequate staffing:
E5 stated that after R1 returned to the facility, she assigned 1:1 staff to R1, but the facility also had 1:1 staff coverage needed for another resident (R3) which "left them pretty short". E5 confirmed that she only had four direct care staff on duty from 9:00 p.m. until the early morning shift came in at 4:45 a.m.. E5 explained that when residents require 1:1 staff intervention, the direct care staff who are assigned to do 1:1 are pulled from the existing staff on duty at that time. She said no additional staff were added to the schedule which left them "short-staffed."
Per review of program books, six additional residents (R2, R3, R7, R13, R14, R15) have behavior plans with methodology to include close supervision, including 1:1 intervention at times, to address either physical aggression, agitation, wandering and/or elopement. However, per review of the facility' staff schedule, no additional staff had been added.
Per interview with E1, Administrator, on 07/17/03 at 2:30 p.m. E1 confirmed that when residents require 1:1 staff intervention, as determined by charge nurse, QMRP, or Developmental Trainer (D.T.) Supervisor, staff are pulled off the floor, from other areas. E1 verified that the facility has "not increased staff yet", and claimed to have had "adequate staff when behaviors have escalated".
C.) Failure to assure staff training:
Per facility's incident report, "a staff member (E21) stated that he heard an alarm go off and went to check it out. E21 found no one in the area, so he shut off the alarm and did not report it to anyone.
Per interview with E5 (LPN) on 07/17/03 at 6:10 p.m., E5 confirmed that the staff who heard the alarm (E21) thought it might have been another resident (R7) who sometimes goes out to look for cigarette butts and then comes right back in. E5 stated that E21 is "new and just didn't know" that he should have reported it.
E5 confirmed that the staff did not do an accounting for all residents, even for the individuals identified as an elopement risk. Review of the facility's policy for elopement states that staff should determine if any resident is unaccounted for, and then should look around the facility including resident rooms and bathrooms.
D.) Failure to develop appropriate corrective action:
Per interview with E9 on 07/21/03, E9 verified that R1 had not been put on any type of monitoring system even after her elopement on 07/04/03.
Per facility records, R1 continued to have incidents of attempted elopement from the facility after 07/04/03. Nursing notes of 07/09/03 and 07/10/03 confirm that R1 was extremely agitated during these incidents and the notes document that R1 left the building.
Interview with E1, Administrator, on 07/17/03 at 7:30 p.m. confirmed that the facility had not increased staffing even though at least three residents are on "1:1 supervision"; nor had staff been trained regarding one on one supervision.
Lack of staff training was confirmed per interview with E2, Marketing Director/QMRP, on 07/17/03 at 2:30 p.m. who stated that she was "not sure what 1:1" coverage actually meant and had received no training on this.
In addition, interview with E9 on 07/21/03 also confirmed that R1 had not been assessed for monitoring needs prior to her elopement on 07/04/03 (even with her history of past elopement attempts) and had not been re-assessed after the 07/04/03 incident even though she has continued to leave the building when agitated.
2. Incident of possible sexual assault of 07/09/03 with documented aggressive behaviors
Per review of R3's chart, R3 is an 18-year-old male who functions at the severe level of mental retardation with additional diagnoses of Cerebral Palsy. R3 is non-ambulatory but is independent with mobility of his wheelchair and can independently transfer self in and out of his wheelchair. R3 came to the facility on 07/03/03 and was admitted on 07/07/03.
R2 is a 19-year-old female who functions at the severe level of mental retardation with an additional diagnoses of Pervasive Developmental Disorder. Review of R2's chart verified that she was admitted to the facility on 06/30/03.
Per review of the facility's incident/accident investigation of incident of 07/09/03, R3 "was found in his bed on top of a female resident (R2). Both residents had their pants on and were attempting to engage in sex".
Per interview with E7, Qualified Mental Retardation Professional (QMRP) on 07/21/03 at 12:30 p.m., E7 confirmed that he had completed a sexuality assessment for R2 on 07/02/03 but had not put it in her chart.
Per review of this document, entitled Human Awareness Assessment, R2 does not know "what sex she is", does not understand "where and when to kiss or hug someone, what sexual intercourse is, what sexually transmitted diseases are", or "how a person gets sexually transmitted diseases".
According to the facility's final investigative report, dated 07/15/03, the incident occurred on 07/09/03 at approximately 6:15 a.m. when staff discovered R3 on top of R2 "moving back and forth" after staff had heard sounds coming from R3's room.
The report states that "both residents had clothing on. (R2) was noted to have blood on under garments in private area (question-possible menses)". The report also states that R2 was taken to the emergency room but "was uncooperative for examination but did allow blood to be drawn for testing. Day after medication given as precautionary measure".
In addition, the report indicates that R2 was also taken to a nurse practitioner (Z6) for examination. Per facility report, Z6 was able to do partial exam which indicated that there probably had not been penetration and there was no blood noted on exam glove".
Interview with E12, Developmental Trainer (D.T.) on 07/23/03 at 2:45 p.m. confirmed that he heard a banging, thumping sound coming from R3's room at approximately 6:15 a.m. on 07/09/03. Upon entry to R3's room, E12 stated that he saw R3 on top of R2 and they were engaging in sex.
E12 stated that he immediately pulled R3 off of R2 and called for female staff to assist R2. E12 said that both R2 and R3 had their clothes on and explained that their pajama bottoms had open plackets in the front and do not fasten. E12 said he couldn't tell if their body parts were exposed because it happened so quickly.
Interview with E14 (D.T) on 07/17/03 at 9:30 a.m. confirmed that when she entered R2's room on 07/09/03, she observed that R2 was dressed and R3 only had his underwear on. E14 stated that she assisted R2 to her bathroom and noticed that she was bleeding. E14 said that she thought R2 was on her menses. E14 stated that she talked with R2 and asked her about the incident with R3. Per E14, R2 said that R3 had "stabbed her" and she "liked it".
A.) Failure to provide nursing follow-up as per recommendation:
Documentation in the nurse's notes dated 06/30/03, stated that, per R2's mother, R2 has not had her menses for over a year since R2 began taking a psychotropic medication.
Per review of nurse's notes and nursing assessments, no monitoring for bleeding or other possible signs/symptoms of trauma to the genital area were documented until 07/11/03 when nurse indicated R2 had "no bleeding" per her body assessment. Per telephone interview with Z6, Nurse Practitioner, who had attempted to examine R2 on 07/9/03, she had instructed the facility to "observe R2 for bleeding".
B.) Failure to conduct thorough investigation and to develop appropriate corrective action:
Per review of the facility's final investigative report of the incident of 07/09/03, the facility's investigation failed to assess and/or address R2 and R3's ability to understand and consent to sexual activity, failed to assess staffing/monitoring needs for R2 and R3, failed to develop a policy to assess adequacy of staffing, failed to train staff in regards to monitoring needs of R2 and R3, and failed to train staff in regards to implementation of behavior plans and retention of evidence regarding a possible sexual assault.
The facility's investigative report also states that "both residents have been counseled about incident but not mentally/cognitively able to full comprehend". Interview with E1, Administrator, on 07/29/03 at
2:00 p.m. confirmed that the facility determined that the incident on 07/09/03 would seem consensual between R2 and R3 because of R2's actions of entering R3's room and climbing into his bed.
However, review of E14's written interview statement dated 07/09/03 verified that she had asked R2 if R3 "had hurt her or touched her in any way and she said yes, I then asked her the same question and asked how, she replied "He stabbed me", and pointed to her private area". Interview with E14 on 07/17/03 at 9:30 a.m. confirmed the above statement as written and E14 also said that after saying R3 had "stabbed her", R2 said she liked it and then started crying.
Interview with E7, Qualified Mental Retardation Professional (QMRP) on 07/21/03 at 12:30 p.m. confirmed that he had completed a sexuality assessment for R2 on 07/02/03 but had not put it in her chart.
Per review of this assessment, R2 does not know "what sex she is", does not understand "where and when to kiss or hug someone, what sexual intercourse is, or what sexually transmitted diseases are", or "how a person gets sexually transmitted diseases".
E7 also confirmed that no programs addressing R2's deficits in the area of human sexuality had been implemented. E7 stated that this assessment was going to be part of the IDT packet at R2's 30-day staffing.
In addition, review of facility's investigation confirmed that R2's clothing had been changed after the incident with R3 on 07/09/03. Interview with E1, Administrator on 07/17/03 at 7:30 p.m. confirmed that R2's clothing had not been kept and bagged for evidence of possible assault, nor had R3's sheets been kept.
Per facility records, training for the facility's nurses and QMRP staff regarding the handling of evidence was not provided until 07/17/03.
Interview with E1, Administrator, on 07/17/03 at 7:30 p.m. also confirmed that the facility had not increased staffing even though R2 and R3 had repeatedly required "1:1 supervision"; nor had staff been trained regarding one on one supervision. E1 also verified that the facility had not assessed R2 and R3 after the incident to determine level of monitoring needed.
Per interview with E1 on 07/28/03 at 2:00 p.m. E1 confirmed that she had tried to contact the local police on 07/09/03 about the incident with R2 and R3 but had not been able to get through. E1 stated that she forgot about it and made no further attempts to report the incident.
Lack of staff training was confirmed per interview with E2, Marketing Director/QMRP, on 07/17/03 at 2:30 p.m. who stated that she was "not sure what 1:1" coverage actually meant and that she had received no training on this.
Interview with E12, DT, on 07/23/03 at 2:45 p.m. confirmed that he had received no training on R3's behaviors until "2 nights ago, after the I.J. was called and they put R3 on constant 1:1".
C.) Failure to develop/implement behavioral objectives and to protect others from harm:
Per R3's clinical record, R3 was admitted to the facility on 07/04/03 after an overnight visit on 07/03/03. Per facility records, R3 began to exhibit aggressive behaviors almost immediately upon arrival on 07/03/03.
Nurse's notes and nursing assessment documentation forms recorded the following incidents regarding R3:
07/03/03 - per nurses' admission assessment - "has had behaviors all of this first p.m. & has required one on one staff to avoid injuries".
Interview with E1 on 07/17/03 at 10:00 a.m. confirmed that she had been contacted on 07/03/03 regarding R3's aggression and had instructed staff to place R3 on 1:1 monitoring.
07/04/03 - "Continues to grab @ others' bodies (crotches/breasts) constantly laughing & making sexual remarks to others. Very demonstrative with use of w/c. Rams into others & chases after others".
07/05/03 - "Has continued to be aggressive toward everyone near him, grabbing their arms & pulling at their pants & grabbing crotches. 1 on 1 staffing maintained. Calls staff & residents terrible names".
07/06/03 - (a.m.) "Res. hitting, grabbing, scratching et running into people on purpose while in w/c. While at meals, throws food at res's et staff".
07/06/03 - (p.m.) "Continues to grab, hit, scratch, bite & running w/c into people. Calls everyone filthy names & uses sexual remarks liberally. Behaviors are constant".
07/07/03 - "spitting, hitting, biting"
07/08/03 - "chasing, grabbing, pinching"
07/09/03 - "Res. had been running in w/c up & down halls being physically and verbally aggressive, trying to grab staff et res's alike in private parts. Also biting, hitting, scratching and pounding on others".
Interview with E9, QMRP, on 07/29/03 at 11:55 a.m. confirmed that behavior plans for R3 were not implemented until 07/09/03. E9 stated that she was not in the building on 07/04/03, 07/05/03, or 07/06/03, but was aware that there had been some incidents, "not physical aggression, but sexually related". E9 also confirmed that she did not have a chance to read the nurse's notes on R3 from 07/03/03 to 07/07/03 "until she was on the way to take R3 to psych unit" on 07/07/03.
Per review, one behavior plan targets R3's physical aggression which addresses "hitting, biting, slapping, etc" and another behavior plan addresses "kissing others, touching others in inappropriate places, trying to rip clothes off others, etc."
However, R3 continued to display aggressive and sexual behaviors after the incident on 07/09/03 and after the behavior plans were implemented as indicated by the following nursing assessments and nurse's notes regarding R3's subsequent behavioral incidents:
07/11/03 - "pinching, hollering, cursing, spitting"
07/12/03 - "pulling DT hair..increased behaviors during meal".
07/13/03 - "grabbing staff & residents clothes, pinching, cussing, hitting".
07/14/03 - "When up in w/c, res grabbing, pinching, cursing @ everyone".
07/16/03 - "Spent 3 episodes of increased behavior chasing & grabbing @ female resident". (Resident not identified.)
07/17/03 - "cursing, spitting"
07/18/03 - "grabbed (female staff's) breast"
07/19/03 - 2:00 p.m. - "res has been wheeling up and down hallway grabbing, biting, cursing, hitting et pinching".
07/19/03 - 8:00 p.m. - "this res. had gotten another res. cornered & was grabbing & hitting @ him......bothered & upset residents in the hall on way to" room.
07/19/03 - 10:00 p.m. - "Behaviors have continued repeatedly during all of resident's waking hours". When awake is "abusive again until his next rest period".
07/20/03 - "Attempting to hit & grabs others...much cursing et yelling with attempts for no reason or provocation to hurt others".
Per review of facility's accident/incident reports of 07/17/03, R3 "pushed his wheelchair beside R5, reached over and grabbed her right breast. R5 screamed & slapped him hard. R3 wheeled himself down the hall......met R8 in the hall, grabbed her left breast. R8 screamed & jumped in the air".
Per review of a behavior record dated 07/19/03 in the facility's documentation book, staff wrote that she "heard R6 scream, I went into the hall & R3 had a hold of R6's shirt, back of shirt at the neck. I moved R3 away from her & told R6 that she was ok. There was a small red mark on the back of her neck. She said he grabbed me".
Per facility records, R6 functions at the severe level of mental retardation, is non-ambulatory and relies on wheelchair with staff assist for her mobility needs.
Per nursing entry of 07/21/03 at 8:45 a.m., "Resident behaviors are still rampant et he is putting our other residents at risk". Nursing entry at 9:30 p.m. confirms that resident was placed on "one on one with staff member around the clock".
In addition, per interview on 07/23/03 at 1:20 p.m. with Z5 at the day training site, R3 had been discharged from the day training program the morning of 07/23/03 due to his behaviors. Z5 described R3's behaviors as physical aggression towards clients and staff, grabbing female clients breasts, and masturbating in front of others. Z5 verified that she and the Program Coordinator had informed the facility of these incidents. Z5 also stated that they had requested behavior programs with a protocol for handling R3's behaviors from the facility but had not received any information.
Per nursing documentation on the physician order sheet, R2 was admitted to the facility on 06/30/03 with the following medications and indications for use: Inderal, 10 mg three times per day for aggression, Depakote Sprinkles 500 mg two times per day for Bipolar and Aggression, Risperdal, 2 mg two times per day for psychosis, and Prozac, 20 mg daily for depression.
Per record review of a nursing assessment dated 07/01/03, R2 had become aggressive, "pushing self past others to get to any visible food item. Requires 1 on 1 when any food is being served, etc."
Per written statement from E5 (LPN) on 07/08/03 at 9:30 p.m., R2 "began chasing after R9 trying to pull his pants off.......then turned her interest to R10 and R3". The statement also reported that R2 "kept fighting" male staff "to get to R10". At 11:45 p.m., E5 documented that R2's "behavior is as strong as when it began...night shift has only 3 DT's & will have a hard time with this problem". At 12:30 a.m., E5 documented that R2 is "still chasing everyone & grabbing at R9 & R3.
Per entries on behavior records found in the facility's documentation book, R2 was observed at 1:00 a.m. on 07/09/03 "running hallways. She was grabbing three different male residents ignoring all attempts to redirect".
Additionally, an entry on a behavior record dated 07/09/03 verified that R2 "was already having behaviors" when night staff arrived for the 11:00 p.m. shift. Per staff's notes, she was "called out on the floor to help get R2 off of R10 without much success. R2 ran the halls all night and went outside four times during my shift".
Another entry on 07/09/03 confirmed that R2 had been observed "climbing into several residents beds".
Interview with E14, DT, on 07/17/03 at 9:30 p.m. confirmed that when she came on duty at 4:45 a.m., the night staff had reported that R2 had gone into several male residents room during the night. R2 stated that R3 and R10 share a room and that she had to get R2 out of R3 and R16's beds some time early the morning of 07/09/03.
Documentation recorded on nursing assessment forms confirmed that R2 continued to display aggressive, sexually inappropriate behaviors after the 07/09/03 incident as indicated by the following nursing entries:
07/10/03 - "irratic/sexually aggressive"
07/11/03 - 2:00 a.m. - "up in hall since midnight...trying to cling to a certain male resident (unnamed) for affection".
07/11/03 - evening shift - "cont. to be aggressive and physical toward others (unnamed), grabbing their clothes & private areas. 1 on 1 staffing needed".
07/13/03 - evening shift - "Shoving people to get to what catches her eye".
07/14/03 - 6:30 a.m. - Stealing food from multiple residents' (unnamed) plates....pushed et pinned female DT to food cart; male DT called to assist. She ran down the halls to shower room, removed her pants et urinated on the floor".
07/14/03 - 12:30 p.m. - "sat in floor next to male resident and wouldn't keep her hands off of him". (unnamed)
07/14/03 - evening shift - "constantly trying to grab male staff & residents in crotch area".
Per review of R2's behavior plan for aggression which was in the documentation book, R2's targeted behaviors were "physical aggression to self and others". However, the short term goal states that R2 "will exhibit 0 episodes of trying to leave the grounds without permission for 3 consecutive months".
The intervention for both behavior plans states that "staff will monitor resident's general mood. Mention to her that we are her friends. Let her know that it is almost time to eat. Remind her that she can call her mother. Redirect her to an alternate activity".
Interview with E7, QMRP, on 07/21/03 at 12:30 p.m. confirmed that he had put the goals and intervention protocol from R2's elopement objective onto her physical aggression objective. E7 admitted that this was confusing and staff may not be documenting incidents of R2's physical aggression.
E7 confirmed that he had not updated R2's behavior plans to address her inappropriate touching and physical aggression until 07/19/03 even though R2's behaviors had escalated.
E7 also verified that he had written the behavior programs because R2 "is non-compliant; wants to touch and hug and can get aggressive". E7 stated that R2 is only aggressive "when she doesn't get her way".
Interviews with E1 and E2 on 07/17/03 confirmed that no one person was reviewing all the data on R2 and R3's behaviors to determine what interventions were needed. Per E1, the nursing documentation is not routinely reviewed by the QMRPs, but she assumes they are reviewing the documentation sheets that the direct care staff report behavioral incidents on.
Interview with E9 on 07/29/03 at 12:30 p.m. also confirmed that a system for tracking and monitoring behaviors was not in place. E9 stated that direct care staff should record behaviors on a behavior intervention sheet but "the nurses are good about" recording incidents in their notes.
Interviews with facility staff, including E3 (Therapy Supervisor), E4 (Staff Development Coordinator), E5 (LPN), E8 (RN/DON), E10 (RN), E12 (D.T.), E17 (D.T.), and E18 (D.T.) all confirmed that they were worried about the safety of residents, especially the ones who can't defend themselves, because of R2 and R3's aggressive behaviors.
E1 and E2 verified that the facility had not developed a system to accurately track behaviors and to develop a protocol for behavioral interventions.
D.) Failure to assure adequate staffing:
Review of the facility's incident/accident investigation report of 07/09/03, confirmed that staff concluded that R2 and R3 "are both physically aggressive toward others & especially toward each other in a sexual manner. They had both been 1 on 1 for this reason, but staff attention was diverted for a few minutes as this is one of the most demanding times of the day". The report also verified that "hectic demands on staff attention at this time of the AM hours" may have contributed to the incident.
Review of the facility's final investigative report, dated 07/15/03, confirmed that R2 "has been on close monitoring protocol since admission. She is programmed for behavior and has had issues of trying to inappropriately touch other residents (male) multiple times requiring long periods of 1:1 interventions".
The report also states that R3 "continues to require considerable 1:1". In addition, nursing documentation of incidents involving R2 and R3, prior to and after the incident of 07/09/03 confirms that frequent 1:1 staff monitoring of R2 and R3 was required.
Interview with E5 on 07/17/03 also verified that they often had to provide 1:1 monitoring to R3 and R4 which required "rearranging staff to accommodate the situation". E5 confirmed that on the night of 07/08/03, R1, R2, R3 and R12 all required 1:1 monitoring at times, but there just wasn't enough staff on duty to provide individual monitoring all the time.
E5 expressed concerns about resident safety due to staffing. E5 stated that after 9:00 p.m., only four direct care staff are on duty with the nurses and after 11:00 p.m., sometimes only three direct care staff are available.
Review of time sheets on 07/08/03 confirmed that 4 developmental trainers were in the facility after
9:00 p.m. and only three were on duty from 10:45 p.m. until the morning shift began at 4:45 a.m.
Review of facility's time sheets also verified that no additional staff were added to the roster when R3 began to exhibit aggressive behaviors when he arrived on 07/03/03.
Facility records, including nurse's notes, verified that 1:1 monitoring for R2 and R3 was only implemented on as needed basis following the incident of 07/09/03.
According to the facility's incident report of 07/17/03, which involved R3's aggression towards two other residents (R5, R8), the Administrator reviewed and signed the report on 07/21/03 noting that R3 "is being monitored closely - 1:1 as needed".
Interviews with E1 and E2 on 07/17/03 and E4 (Staff Development Coordinator) on 07/21/03 all confirmed that no additional staff had been added to the roster. E1, E2 and E4 explained that when 1:1 intervention was required, staff were pulled from another area and assigned to the resident needing individual monitoring.
E.) Failure to notify Administrator of possible sexual assaults and R3's aggressive behaviors towards others:
Per R3's behavior incident record dated 07/04/03 in the documentation book, R3 was observed "pinning (R4) against the wall and kiss her". Another entry on 07/04/03 stated that staff had observed R1 and R3 "in the hallway, hugging, kissing and caressing each other". A third entry was made on 07/04/03 on a behavior record that staff heard R3 yelling as he walked by the dining room and when he went in there, he and R11 had their wheelchairs "interlocked from (R11) ramming him, but the reason (R11) was ramming because R3 was trying to grab R5 in the private area". Staff wrote that R11 "was just trying to save" R5. Interview with E12, Developmental Trainer, on 07/23/03 at 2:45 p.m. confirmed that he had observed R3 biting and pinching other residents. E12 also verified that on 07/04/03 he saw R3 pin R4, who functions at the profound level of mental retardation, against the wall and put his hands under her shirt and was kissing her. E12 stated that he has observed R3 "go after" R4 several times until the facility recently put R3 on 1:1 with staff.
In addition, E12 stated that he observed R3 propel his wheelchair in front of R1's door, prevented her from leaving and started to grope her. E12 said that R1 then struck R3.
Interview with E1, Administrator, on 07/17/03 at 2:30 p.m. confirmed that she had not been informed about R3's sexual aggression towards R1, R4, and R5 and that no investigation had been conducted.
F.) Failure to obtain accurate assessments/background information and to involve Interdisciplinary Team prior to resident admissions:
Per review of facility records, R3 first came to the facility on 07/03/03 and was admitted on 07/07/03.
Review of the facility's Pre-Admission Evaluation for R3, dated 07/03/03, confirmed that no information of assessments, such as psychological, developmental, or social history had been recorded and that no signatures from members of the IDT were obtained.
According to the pre-admission form, R3 exhibited the behavior of inappropriate "touching - mostly staff, maybe residents too..throwing objects...steals from roommate...food theft".
Interview with E2, Marketing Director, on 07/17/03 at 2:30 p.m. confirmed that she "did not have a lot of information" on R3 because he was "an emergency admit" from another facility. E2 also verified that R3 came to the facility for a visit on 07/03/03 and was then admitted on 07/07/03 even though R3 had required 1:1 staff intervention from the first day due to R3's aggressive behaviors.
Telephone interview with Z4 from R3's prior facility on 07/21/03 at 4:10 p.m. confirmed that she had met with 2 staff from the facility on 07/03/03 and gave them what information she had on R3, including the behaviors he was exhibiting at her facility. Z4 stated that she informed facility staff that R3 had been "hitting residents, running over them with his wheelchair" and had been sexually aggressive toward female residents.
Confidential interviews with facility's IDT members confirmed that they knew very little about R3 and only agreed to a trial visit. Staff members also verified that they were not involved in the final decision to admit R3 and would definitely not have recommended his admission to the facility due to his aggressive behaviors.
Review of R2's chart verified that R2 was brought to the facility on 06/29/03 and admitted on 06/30/03.
Per interview with E2 on 07/17/03 at 2:45 p.m. confirmed that R2's mother brought R2 to the facility for what E2 thought was a visit on Sunday, 06/29/03. However, per E2, R2's mother brought all of R2's things and assumed that R2 was being admitted. E2 confirmed that R2's mother also brought some of R2's school records, but "it was pretty old". In addition, E2 verified that R2 was then admitted the next day, on 06/30/03.
Review of the School Nurse Assessment Re-evaluation From, dated 03/26/03, confirmed that R2 had required psychiatric admissions in 5/00, 8/02 and 3/03. The report indicates that "presently (R2) is hospitalized psych unit for her out of control behavior since 03/20/03. Hx of significant emotional/behavior concerns are reported". However, no information from the hospital regarding these admissions was found in R2's chart.
Per interview with E2 confirmed that no one from the facility had requested any records from the hospital where R2 had recently received psychiatric care in 3/03.
Per review of the Attending Psychiatrists' Assessment from R2's first psychiatric admission, dated 05/04/00, R2 "was admitted for he first psychiatric hospitalization because of increasingly unmanageable dangerous behavior. The patient has knocked down and assaulted brother who is about 200 pounds. She has shown tremendously dangerous behavior, has attempted to jump out of a moving van twice. The patients also would use a weapon and at times stand over mother's bed in a very threatening stance with a knife in her hand".
Per review of the facility's Pre-Admission Evaluation, dated 06/29/03, no information was filled in regarding R2's functioning level, health status, dietary needs, psychological information, social history, interests, likes, dislikes, needs and strengths. However, it was noted that members of the Interdisciplinary Team (IDT) had signed the pre-screening document.
Confidential interviews with members of the facility's IDT confirmed that they had only signed the pre-admission evaluation form agreeing to an initial visit for R2. Staff verified that they were not consulted about formally admitting R2 and would not have recommended her admission to the facility due to the aggressive behaviors (grabbing males, flashing her shirt exposing self, knocking residents out of the way to get to food) that R2 had been exhibiting since she came to the facility. The IDT also confirmed that they had not been informed about the violent nature of R2's behaviors and had not seen the information from the 5/4/00 report.
In addition, telephone interview with Z2, Psychologist, on 07/21/03 at 4:00 p.m. verified that he was also a member of the Interdisciplinary Team, but he had received no information about R2 and R3 and had not been contacted prior to their having been admitted to the facility. Z2 confirmed that he never gets information about new residents "until he sees the clients for their 30-day staffing".
Per review of the facility policy on abuse and neglect, it states that the facility will not allow neglect. Based on Example #1 and #2, the facility failed to implement this policy.